Key Points
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The mainstay treatment for displaced extra-articular distal radius fractures with limited metaphyseal comminution is closed reduction and plaster immobilization. However, not all patients benefit.
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Carpal alignment and coronal plane translation are less familiar parameters to surgeons but important reduction criteria for these extra-articular distal radius fractures.
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Patients aged 18–75 years benefit from early open reduction and volar plate fixation, notably in more comminuted fractures.
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Optimal plate and screw positioning will decrease likelihood of tendinitis or tendon rupture.
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In case of more extensive metaphyseal comminution, (longer) volar plates, various methods of external fixation and intramedullary nailing result in comparable good outcomes.
A 55-year-old, right-handed female interior decorator visits the emergency department with a swollen and deformed right wrist after a fall from a horse on the outstretched hand. Radiographs show an extra-articular distal radius fracture with 20 degrees of dorsal angulation and dorsal metaphyseal comminution ( Fig. 1 ). After closed reduction 15 degrees dorsal angulation persists ( Fig. 2 ).
At the same time a 97-year-old lady comes in with a comminuted metaphyseal DRF as part of a distal forearm fracture and associated 2 cm-wound on the volar ulnar side ( Fig. 3 ).
Which treatment is most effective for these comminuted extra-articular distal radius fractures?
Importance of the Problem
One in six fractures are distal radius fractures (DRFs). Moreover, in the United States 600,000 DRFs are diagnosed every year causing 480 million USD of direct cost of care. As the population continues to age, the burden of distal radius fractures and the direct and indirect healthcare costs are expected to increase.
Overall incidence for DRFs in adults is 20 per 10,000 person-years. Extra-articular fractures are most common with an estimated incidence of 50%. However, these figures are based on conventional radiographs. When using CT scans, the true incidence of AO type A fractures may be lower.
For displaced extra-articular distal radius fractures with limited comminution closed reduction and plaster immobilization is recommended as the treatment of choice. However, secondary dislocation is common and may result in poor patient-rated outcomes if left untreated. Therefore, the question remains what the most effective therapeutic approach for comminuted extra-articular DRFs is?
Accurate assessment of standard radiographs is essential for appropriate treatment of extra-articular DRFs ( Box 1 , Fig. 4 ). Fracture anatomy and the degree of displacement may guide treatment.
Posterior Anterior View
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Radial inclination: Measures from the tip of radial styloid process (PSR) to the center point of the ulnar side of the distal radius. This center point (CRP) is located between the volar and dorsal rim which can easily be identified on the PA radiograph. Radial inclination is normally 20–25 degrees.
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Ulnar Variance: The distance between the CRP and distal articular surface of the ulna. Normally + 0.9 mm (range − 4.2 to 2.3 mm).
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Radial length: is defined by the length measured between the tip of the radial styloid and the distal articular surface of the ulna. Normally 10–13 mm.
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Coronal plane translation : is used to describe radial displacement of the distal fragment. Radial translation of the distal fragment might be associated with DRUJ instability due to lack of tension on the distal oblique bundle (the most distal part of the distal interosseous membrane) and the pronator quadratus. Coronal plane translation can be measured by drawing a line on the ulnar side of the radius which intersects the lunate. The point of intersection within the lunate is evaluated by drawing a second line along the transverse width of the lunate parallel with the distal joint. In a normal situation the lines should bisect at 50%.
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In a congruent DRUJ the ulnar side of the distal radius and radial side of the ulna should converge in the form of a Gothic arc. This arc should not be interrupted.
Lateral View
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On a pure lateral radiograph, the pisiform projects over the distal pole of the scaphoid, between the distal pole of the scaphoid and the capitate. Only then, can the surgeon assess volar or dorsal dislocation of the ulna.
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Volar tilt: Angle between a line drawn through the center of the radial shaft and a line drawn through the apices of the palmar and dorsal rims of the radius. The normal volar tilt is between 5 and 11 degrees
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Carpal alignment: It is measured by drawing a line along the inner rim of the volar cortex of the radius (marginal line of Lewis) and determining the center of the capitate. (The center of the capitate is at the center of a circle drawn around the base of the capitate.) The carpus is aligned when the line along the inner rim transects the center of the capitate. By measuring the perpendicular distance to the center of the capitate, the degree of carpal malalignment can be quantified. Carpal malalignment is correlated with poor functional outcome. Based on the study of Selles et al., a margin of 0.5 cm of dorsal and 0.5 cm of volar displacement would be within the range of normal alignment ( Fig. 5 ).
The definition of a dislocated extra-articular fracture is when extra-articular radiologic parameters are not within the normal ranges as described in Box 1 . In most situations, a closed reduction will be performed followed by a radiograph. However, what radiographic anatomy can we accept to continue nonoperative treatment? Historically, Lafontaine’s criteria were used as the main guideline (See Chapter 9 ). Currently, the AAOS guidelines advise nonoperative treatment for fractures with post reduction radial shortening < 3 mm and dorsal tilt of < 10 degrees. On the contrary, the Dutch guidelines are more liberal: less than 10 degrees tilt in any direction and less than 5 mm radial shortening. If all of these are applicable, conservative treatment is advised.
In 2015, a systematic review was performed by Walenkamp et al. to identify predictors of secondary displacement in DRFs. Female gender, age over 60 and dorsal comminution were significant predictors for secondary displacement. Associated ulnar styloid fractures, initial dorsal angulation > 20 degrees or articular involvement were found to be nonsignificant.
Main Question
What is the most effective therapeutic approach for comminuted extra-articular displaced DRFs?
Current Opinion
The mainstay treatment of displaced extra-articular DRFs with limited comminution in adults is closed reduction and immobilization in a cast. However, even in case of adequate reduction, secondary dislocation of the fracture occurs in up to 60% of cases. In recent years operative treatment of extra-articular DRFs with open reduction and fixation with a volar locking plate has become increasing popular. Open reduction and volar plate fixation allows for early mobilization and therefore may lead to improved functional outcome. In case of more extensive metaphyseal comminution, longer volar plates with optional bone grafting ( Fig. 6 ) or alternative solid constructs such as bridging spanning plates, or external fixation are recommended.
Finding the Evidence
Search algorithms used to retrieve evidence for the main question:
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Cochrane search: “distal radius fracture” OR “distal radial fracture” AND “plate fixation” OR “open reduction internal fixation”
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Pubmed (Medline): (((((“Radius Fractures”[Mesh] OR “distal radius fractures”[TIAB]) OR “distal radius”[TIAB]) OR Radius Fractures[TIAB]) AND (((((“Casts, Surgical”[Mesh] OR Casts[TIAB]) OR “Splint”[TIAB]) OR “Splinting”[TIAB]) OR casting[TIAB]) OR (((plate[TIAB] OR plating[TIAB]) OR orif[TIAB]) OR open reduction internal fixation[TIAB]))) OR ((((((“Radius Fractures”[Mesh] OR “distal radius fractures”[TIAB]) OR “distal radius” [TIAB]) OR Radius Fractures[TIAB]) OR “forearm fractures”[TIAB]) AND (((((“Casts, Surgical”[Mesh] OR Casts[TIAB]) OR “Splint”[TIAB]) OR “Splinting”[TIAB]) OR casting[TIAB]) OR (((plate[TIAB] OR plating[TIAB]) OR orif[TIAB]) OR open reduction internal fixation[TIAB]))) AND (“Fracture Fixation, Intramedullary”[Mesh] OR “Fracture Fixation, Internal”[Mesh]))) AND (Dutch[lang] OR English[lang] OR German[lang])
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Only comparative studies were reviewed
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Only articles written in English, French or German were included
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Study protocols or abstracts of oral or poster presentations at congresses were excluded
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Article solely focusing on intra—or partial articular fractures were excluded
Quality of the Evidence on VLP vs Cast
Level I:
Randomized trials: 2
Level II:
Randomized trials with methodological limitations: 3
Level III:
Retrospective comparative studies: 3
Quality of the Evidence on Other Types of Surgery
Level I:
Randomized trials and systematic reviews: 6
Level II:
Randomized trials with methodological limitations: 5
Findings
This chapter focuses on nonoperative treatment versus plate fixation in adult patients with extra-articular DRFs with a variable degree of comminution. A meta-analysis of Vannabouathong et al. concluded that open reduction and plate fixation offers the best results for adult patients with a DRF, in terms of radiological and functional outcome and fracture healing. However, naturally other less invasive operative techniques have been described to treat DRFs such as closed reduction and Kirschner wire fixation, various methods of (non-)bridging external fixation, and intramedullary nailing. As ORIF with a volar locking plate (VLP) is the mainstay, it will be the primary focus of main part of this review, while alternative methods of fixation will be discussed at the end. Randomized controlled trials or comparative cohort studies evaluating plate fixation versus closed reduction and cast immobilization of displaced distal radius fractures in adults were included. Most studies included elderly with AO Type A and C DRFs.
Evidence From Level-1 VLP Studies
We have deemed the studies from Mulders et al. the only level-1 evidence available to the main question considering that the other articles either also included intra-articular fractures or focused on the elderly.
Mulders et al. randomized 92 patients (ages 18–75) with acceptably reduced extra-articular distal radius fractures between volar plate fixation (VLP) and cast immobilization (CI). At 6 weeks, 3 months, 6 months, and 12 months follow-up the VLP group had significant better DASH, PRWE scores and radiographic parameters ( Fig. 7 ). However, at 12 months differences were below the MCID threshold. At 12 months VLP patients had significantly better flexion (80 degrees [70–86] vs 70 degrees [60–80] P < .01), extension (85 degrees [80–90] vs 80 degrees [70–90] P < .01), pronation (90 degrees [80–90] vs 85 degrees [75–90] P < .01), supination (85 degrees [75–90] vs 75 degrees [70–85] P < .01) and grip strength (26 kg [19–35] vs 20 kg [17–29] P < .01). Twenty eight percent of the CI patients had early fracture dislocation which was managed with VLP. Fourteen percent of the patients in the CI group developed a symptomatic malunion for which a correction osteotomy was performed.
